An overview of telemedicine services in health care today as well as some specifics related to physical therapy practice.
Kelly Sanders, PT, DPT, OCS, ATC
Advances in both medical as well as communication technology have paved the way for the rise of telehealth. According to the American Telemedicine Association, more than 15 million Americans received some type of medical care remotely last year, and that number is expected to grow by 30 percent this year. Communication technology is allowing physicians and other health care providers to be accessible to patients for urgent care as well as specialty care when it may not otherwise be immediately locally available. This health care delivery medium has also increased the convenience of not having to physically visit a health care provider’s office or a specialty health facility. In addition, it is allowing for health care providers to access colleagues within the medical community, specifically in rural or underserved areas where a specialist may not be available locally for consultation. Telehealth becoming mainstream will make a significant impact on health care and should afford the health care community the ability to improve care delivery, access, and cost.
The New England Journal of Medicine recently published an article on the state of telehealth and identified three primary telehealth trends, the first being that telehealth is evolving from a medium that started initially as a means to improve access to care yet also is increasing convenience and will hopefully eventually lower health care costs. Second, we are seeing the migration from services for acute care conditions to now seeing telehealth grow to address more chronic conditions. The last significant trend identified is that telehealth is now not just being utilized in hospitals, facilities, and medical offices but in patient homes or on mobile devices.1
With this increased utilization and access to telehealth services, hurdles have appeared. Laws, regulations, and payment policy vary greatly by state, specialty, and payer. Given the infancy of this provider medium, each area of the health care dynamic is being evaluated with new legislation and policy being introduced. The types of care that are appropriate for the telehealth medium are starting to be defined, as well as guidelines for telehealth care.
Payment is likely the largest constraint to large-scale use of telehealth. The Centers for Medicare & Medicaid Services (CMS) is proposing expanded coverage of telehealth services with new Current Procedural Terminology (CPT) codes scheduled to go into effect in January of 2017. Currently, much of this care is limited to specific health care specialties, commonly in the areas of behavioral health, renal care, and other critical care areas. At present, CMS also limits the location of telehealth care, requiring that the patient be located in a medical office or facility (originating site requirement). One new proposed exception to this is home care under the Comprehensive Care for Joint Replacement (CCJR) program.
Despite limitations with telehealth payment success to date, the use of telehealth is on the uptick in organizations and agencies that have more financial risk or where costs are more closely embedded in the delivery of care. Examples of this are the Department of Defense, the Department of Veterans Affairs, and larger self-insured employers.
As telehealth relates to physical therapy, there are additional challenges to work through. Third party payer coverage is significantly limited or unavailable, and CMS does not recognize physical therapists as eligible providers of telehealth care at this time. In 2015, the Federation of the State Boards of Physical Therapy published Policy Recommendations for Appropriate Regulation for telehealth in physical therapy.2 This document outlines the regulatory requirements specifically related to licensure as a physical therapist. At the time of publication, only three states have specific language related to physical therapy telehealth practice, so practice act and in-person regulatory standards prevail in most cases. Physical therapist licensure is required in whichever state the patient is physically located in at the time of care, and all regulatory and practice act guidelines apply based on the state the patient is physically located in as well.
Given all of the specifics for physical therapy, significant possibilities exist to integrate telemedicine into our care paths and services. As we look toward changes in payment, telemedicine may be a key component of bundled and value-based payment models. This may be a tool for practices to keep costs in check, and integrate telemedicine visits between “brick and mortar” clinic-based care for specific conditions. As an example, it seems logical that for a postoperative patient who underwent rotator cuff repair, we can see the patient in the clinic once a week and monitor progress and check status between weekly in-clinic visits via a telemedicine visit.
Overall, as this medium of care evolves it appears multiple positives related to access, convenience, and cost control will be available to our patients, practices, and providers. Continuing to follow solid evidence-based care guidelines, a responsible and thoughtful approach to patient selection for this medium of care delivery and continued focus on the patient experience should ensure success.
Kelly Sanders, PT, DPT, OCS, ATC, is president of Movement for Life, Inc, a group of physical therapy clinics operating in California, Arizona, and North Carolina. She is a member of the APTA PPS Payment Policy Committee as well as the Editorial Board of Impact magazine. She can be reached at firstname.lastname@example.org.
1. Dorsey ER, Topol, EJ. State of telehealth. N Engl J Med. 2016;375;2:154-160.
2. Federation of State Boards of Physical Therapy. Telehealth in physical therapy: policy recommendations for appropriate regulation, 2015.